Provider Demographics
NPI:1295084440
Name:WINDSOR PALM VALLEY, LLC
Entity type:Organization
Organization Name:WINDSOR PALM VALLEY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER, WINDSOR OMG HOLDIN
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-385-1090
Mailing Address - Street 1:9200 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3502
Mailing Address - Country:US
Mailing Address - Phone:310-385-1076
Mailing Address - Fax:310-595-3736
Practice Address - Street 1:13575 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2604
Practice Address - Country:US
Practice Address - Phone:623-536-9911
Practice Address - Fax:623-536-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035255Medicare Oscar/Certification